Mental incapacity andmedical ethics

With reference to the editorial by Sarkar & Adshead (2003), we are pleased to see this area of discussion being raised. However, we wish to make a couple of additional points relating to capacity.

We appreciate that a psychiatrist's ability to override a competent refusal raises particular ethical dilemmas and it is right that this should be highlighted for attention. However, we felt that other points in the section ‘Psychiatry as a special case’ could, and do, apply to many non-psychiatric patients, particularly those with acute medical illness.

The authors assert that ‘The most significant difference between medicine and psychiatry lies in the relative incapacity of psychiatric patients to make decisions for themselves’. Although it is true that some of the most severely affected patients have impaired decision-making skills, they form a minority (Grisso & Appelbaum, 1995). Most psychiatric patients (including in-patients) are perfectly capable of making decisions regarding treatment and other areas of their lives. It does not help the cause of reducing stigma for our patients to suggest that they cannot make such decisions.

Just as not all psychiatric patients lack capacity, not all medical patients have capacity. This particularly applies to inpatients in whom factors such as cognitive impairment and delirium can affect the ability to make decisions. A recent survey of medical in-patients found that mental incapacity was a very common problem, and one that was frequently overlooked by medical staff (further details available from V.R. upon request). These patients are particularly vulnerable to medical paternalism if this problem is not recognised and appropriately managed.

We agree with Sarkar & Adshead's call for a code of ethics for British psychiatry, and hope that it will address this difficult area of incapacity. Incidentally, we are also watching with interest the progress of the draft Mental Incapacity Bill. However, we suggest that this area requires careful scrutiny not because psychiatry is a ‘special case’ but because these issues affect all health care professionals. In this way we could help to lead the way for our non-psychiatric colleagues rather than concentrating on our differences.